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State & Local Government Solutions Medicaid Information Technology System (MITS)

Glossary T3D022_Glossary.doc

Version 4.1

June 12, 2009

Electronic Data Systems 50 W. Town Street

Suite 100 Columbus, OH 43215

Ohio MITS – Glossary June 12, 2009

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© 2009 Hewlett-Packard Development Company, LP

Document Information Document Title Glossary Document ID T3D022_Glossary.doc Version 4.1 Owner Deliverables Team Author Maria Burk

The controlled master of this document is available online. Hard copies of this document are for information only and are not subject to document control.

Amendment History Document Version#

Submission Date

Modified By Modifications

1.0 Cynthia Brandt Initial delivery 1.1 10/04/07 Cynthia Brandt BPA definitions added 1.2 10/11/07 Cynthia Brandt ClearCase definitions added. This version

was not submitted to ODJFS for review. 1.3 Cynthia Brandt Revisions based on State comments 2.0 04/11/08 Cynthia Brandt Updates for Iteration 2 2.1 05/06/08 Cynthia Brandt Revisions based on State comments,

including the addition of terms and acronyms from the Ohio Medicaid Report 2005.

3.0 06/30/08 Cynthia Brandt Updates for Iteration 3 4.0 05/07/09 Cynthia Brandt Updates for Iteration 4 4.1 06/12/09 Cynthia Brandt Updates based on State comment log

(06/05/09) and additional materials related to the new bureau alignment..

EDS and the EDS logo are registered trademarks of Hewlett-Packard Development Company, LP. HP is an equal opportunity employer and values the diversity of its people.

© 2009 Hewlett-Packard Development Company, LP Some definitions within this document are from Wikipedia

and used under its GNU Free Documentation License, Version 1.2


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Table of Contents Introduction................................................................................................................1

0-9 .......................................................................................................................................... 1 A............................................................................................................................................. 2 B........................................................................................................................................... 10 C........................................................................................................................................... 18 D........................................................................................................................................... 28 E........................................................................................................................................... 35 F ........................................................................................................................................... 40 G........................................................................................................................................... 45 H........................................................................................................................................... 47 I ............................................................................................................................................ 52 J............................................................................................................................................ 59 K........................................................................................................................................... 60 L........................................................................................................................................... 61 M.......................................................................................................................................... 64 N........................................................................................................................................... 70 O........................................................................................................................................... 75 P ........................................................................................................................................... 81 Q........................................................................................................................................... 89 R........................................................................................................................................... 90 S ........................................................................................................................................... 95 T......................................................................................................................................... 105 U......................................................................................................................................... 108 V......................................................................................................................................... 110 W........................................................................................................................................ 111 X......................................................................................................................................... 114 Y......................................................................................................................................... 115


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INTRODUCTION The following glossary is a combination of listings from a glossary developed by the Ohio Department of Job and Family Services (ODJFS) and the standard EDS Medicaid glossary. This is a living document that will continue to be updated throughout the life of the project.

Terms in the first column are entered either by acronym or spelled out if there is no acronym. All terms and acronyms are shown with the proper capitalization for common usage in the first column. As an example, ‘active treatment’ is not capitalized in common usage but ‘Drug Rebate Program’ is capitalized. Acronyms are spelled out in the Definition column but only capitalized if they are proper nouns. As an example, ADA is rendered as ‘Americans with Disabilities Act’, while ACG—‘ambulatory care groups’ is not capitalized.

Where more than one definition exists for an acronym, the most common usage is given first.

Numeric Terms Term Definition

0-9 209-B State determines eligibility for the Medicare Buy-in program.


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A

A1I1 Application (A) Production Release 1 (1) Iteration (I) Iteration 1 (1) A1I2 Application (A) Production Release 1 (1) Iteration (I) Iteration 2 (2) A1I3 Application (A) Production Release 1 (1) Iteration (I) Iteration 3 (3) A1I4 Application (A) Production Release 1 (1) Iteration (I) Iteration 4 (4) A2I1 Application (A) Production Release 2 (2) Iteration (I) Iteration 1 (1) AAA Area Agency on Aging

Established under the Older Americans Act (OAA) in 1973 to respond to the needs of Americans 60 and over in every local community. By providing a range of options that allow older adults to choose the home and community-based services and living arrangements.

AAP American Academy of Pediatrics An organization of pediatricians and physicians trained to deal with the medical care of infants, children, and adolescents.

ABCD Assuring Better Child Development Designed to assist states in improving the delivery of early child development services for low-income children and their families.

ABD Aged, Blind or Disabled Category of Medicaid assistance as described in division (A) (2) of Section 5111.01 of the Ohio Revised Code.

ABLE Adult Basic Literacy Education A program that provides quality leadership for the establishment, improvement and expansion of lifelong learning opportunities for adults in their family, community and work roles.

ACD automatic call distribution A device or system that distributes incoming calls to a specific group of terminals that agents use.

ACE access control entry Describes access rights associated with a particular security identifier (SID). The access control entry is evaluated by the operating system in order to compute the effective access granted to a particular program based on its credentials.

ACF Application Change Form A form requesting a change in policy.

ACG ambulatory care groups All types of health services that do not require an overnight hospital stay.


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ACN attachment control number Represents a unique identification number for the document associated with an electronic bill transaction. Applies to all pages associated with a multiple page document.

ACR Automated Cost Reporting Refers to the software used for cost reporting. Ohio nursing facilities (NFs) and intermediate care facilities for the mentally retarded (ICFs-MR) are required to submit cost reports electronically in accordance with Ohio Administrative Code (OAC) Rule 5101:3-3-20 to facilitate cost reporting by providers.

ACS Affiliated Computer Services The pharmacy contractor for the Ohio Medicaid program.

action item An action item is typically a unit of work assigned to an individual at a meeting and reviewed at subsequent meetings until the item is closed.

active treatment A term associated with care in an Intermediate Care Facility for the Mentally Retarded (ICF-MR) and means a continuous treatment program that includes aggressive, consistent implementation of a program of specialized and generic training, treatment, health services and related services for individuals with mental retardation and/or other developmental disabilities that is directed toward the acquisition of the behaviors necessary for the individual to function with as much self determination and independence as possible; and the prevention or deceleration of regression or loss of current optimal functional status. Active treatment does not include services to maintain generally independent individuals who are able to function with little supervision or in the absence of a continuous active treatment program.

ACTS Advanced Case Tracking System Used in case management to oversee and administer the services provided to a consumer.

ad hoc Used to refer to a type of non-standard report created for a specific request. ADA 1. Americans with Disabilities Act

Enacted in 1990, prohibits discrimination against persons because of their disabilities. The ADA serves as a “comprehensive national mandate for the elimination of discrimination against individuals with disabilities.” (42 U.S.C. 12101(b)(1)) The ADA targets three major areas: Title I addresses discrimination by employers; Title II addresses discrimination by governmental entities; and Title III addresses discrimination in public accommodations operated by private entities.


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ADA 2. American Dental Association A voluntary association of dentists in the United States which sets standards for the dental profession and advocates on behalf of dentists and patients. There are nine recognized specialty areas of dental practice: dental public health, endodontics, oral and maxillofacial pathology, oral and maxillofacial surgery, orthodontics and dentofacial orthopedics, pediatric dentistry, periodontics, prosthodontics, and oral and maxillofacial radiology.

ADC Aid to Dependent Children Former name for Ohio Works First. See: OWF (Ohio Works First).

ADD Assistant Deputy Director Senior staff position in the Ohio Department of Job and Family Services.

ADF automated document feeder Allows user to copy documents without lifting the platen. Instead of placing each sheet individually on the glass, the user loads a stack of documents into the feeder and the copier will move each sheet on and off the platen.

adjudicate To determine whether all program requirements have been met and whether the claim or encounter data can be paid or denied

adjudicated claim A claim for which automatic processing has been suspended in order for an adjudication clerk to manually determine if it should be paid or denied. When a claim is denied, the clerk assigns one or more explanation of benefits (EOB) that give details why the claim was denied. After adjudication, the claim is referred to as an adjudicated claim.

adjustment A transaction that changes any payment information on a previously paid claim.

ADL activities of daily living Things a person normally does in daily living including any daily activity performed for self-care (such as feeding, bathing, dressing, grooming), work, homemaking, and leisure.

ADO Active-X Data Objects A set of Component Object Model (COM) objects for accessing data sources developed by Microsoft. It provides a layer between programming languages and OLE DB (a means of accessing data stores, whether they be databases or otherwise, in a uniform manner). ADO allows a developer to write programs that access data without knowing how the database is implemented.


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AG 1. assistance group Group of consumers receiving benefits together under a specific category of assistance.

AG 2. Attorney General The chief law officer of the State of Ohio.

aged An eligibility category for people 65 and older whose income and resources are within Medicaid limitations.

AGO Attorney General’s Office The division within the executive branch of state government overseen by the Attorney General.

AHFS American Hospital Formulary Service (Drug Information) The premier drug information database, providing an evidence-based foundation for safe and effective drug therapy.

AHRQ Agency of Healthcare Research and Quality (formerly the Agency for Healthcare Policy and Research) Agency dedicated to improving the quality, safety, efficiency, and effectiveness of health care for all Americans.

AHS Automated Health Systems A contractor with ODJFS responsible for Medicaid Consumer Hotline Services and Medicaid Managed Care Enrollment Center Services.

aid category An alpha and numeric code identifying the criteria used to determine an individual’s eligibility.

AIM Advanced Information Medicaid Used in the Oracle Administration Manual, refers to EDS proprietary legacy interChange system.

AIX® IBM’s distribution of AT&T’s System V UNIX. alert The terms alert and notification are used interchangeably to indicate a

signal or message sent from one program or person to another to indicate a status change, a need for action, or to pass information. The method for alerting will vary, depending on the business process and the nature of the alert/notification.

allowable amount The amount/portion of a claim that Medicaid will approve for a covered service

ALW Assisted Living Waiver A federal program to permit Medicaid to cover assisted living expenses for qualified individuals.


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AMA American Medical Association A voluntary association of physicians in the United States which sets standards for the medical profession and advocates on behalf of physicians and patients.

Amount, Duration and Scope

How a Medicaid benefit is defined and limited in a Medicaid State Plan. Each state defines these parameters, thus what is actually covered varies by state plan.

ANSI American National Standards Institute A private non-profit organization that oversees the development of voluntary consensus standards for products, services, processes, systems, and personnel in the United States. The organization also coordinates U.S. standards with international standards so American products can be used worldwide.

AO adjudication order The order in which suspended claims are adjudicated.

AOS Auditor of State Serves as the general accountant of a given State and keeps financial records of various offices and agencies.

AP accounts payable A file or account that contains money that a person or company owes to suppliers, but has not paid yet (a form of debt).

AP-DRG All Patient Diagnosis Related Group An All Patient DRG is an expansion of a basic DRG to be more representative of non-Medicare populations such as pediatric patients.

APD Advanced Planning Document Design, Development, and Implementation (DDI) plans for a Medicaid Information Technology System (MITS).

APG ambulatory patient group A classification system for outpatient services reimbursement developed for the American Medicare service by the Health Care Financing Administration.

API Application Programming Interface A source code interface that an operating system, library, or service provides to support requests made by computer programs.

APR-DRG All Patient Refined Diagnosis Related Group An All Patient Refined DRG incorporates severity of illness subclasses into an all patient DRG. The APR-DRGs expand the basic DRG structure by adding four subclasses to each DRG that address patient differences relating to severity of illness and risk of mortality.


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AR accounts receivable Accounting transactions dealing with the billing of customers who owe money to a person, company or organization for goods and services that have been provided to the customer.

ARNP advanced registered nurse practitioner A registered nurse with advanced training and certification.

ASC 1. Ambulatory Surgery Center A health care facility that specializes in providing surgery, pain management and certain diagnostic services in an outpatient setting.

ASC 2. Accredited Standards Committee Develops electronic data interchange (EDI) standards and related documents for national and global markets.

ASCII American Standard Code for Information Interchange A character encoding based on the English alphabet. ASCII codes represent text in computers, communications equipment, and other devices that work with text.

ASP Active Server Pages Microsoft's first server-side script engine for dynamically generated Web pages. It was initially marketed as an add-on to Internet Information Services (IIS) via the Windows NT 4.0 Option Pack, but has been included as a free component of Windows Server since the initial release of Windows 2000 Server.

ASPAP All Service Plan Approval Process A specified process for approvals. A consumer is assigned a funding range based on the individual service plan. As long as the consumer’s service requirements remain within the assigned funding range, the consumer’s participation is managed by CareStar. When the consumer requires or requests services that exceed the funding range, BHCS must approve those requests.

ASPEN Automated Survey Process Environment A database used for handling nursing home licensing and survey information.

assignment plan This is a group of covered services (benefits) a consumer must receive from a designated provider or provider organization. Reimbursement of services is on a fee-for-service or capitation basis. Assignment plan examples include consumer assignments to a Long Term Care facility or a Managed Care Organization in order to receive covered services (benefits). The consumer must also be enrolled in a Benefit Plan that covers the service. There are several types of assignment plans and each type supports a different model of assignment. In all cases, assignment plans only restrict


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how services are delivered and do not grant coverage. Following are examples of existing assignment plans. Level of Care: Use this type of assignment for Long Term Care situations where a consumer may need to be in an institution other than a hospital to receive certain services, such as skilled nursing, intermediate care, or developmentally disabled rehabilitation. Lock-in: This is the traditional lock-in assignment model where a consumer must receive benefits from a certain provider. This situation occurs when a utilization review determines a consumer is inappropriately using their medical card and restricts them to assigned lock-in medical providers. Standard assignments for lock-in consumers are a physician and pharmacy and can include a hospital depending on inappropriate use of emergency room or outpatient services. Managed Care: This benefit type supports the capitated managed care model, which is any form of health plan that provides health care services to consumers by using a single doctor, case manager, or organization. This model is an attempt to emphasize preventive health care and reduce utilization of unnecessary and high cost care. PCCM (Primary Care Case Management): another common managed model where a consumer is assigned a gatekeeper or primary care provider (PCP) who directs the care of the consumer.

assignment plan hierarchy

Assignment plan threads are a way to control assignment plan relationships and the order of claim processing at the Assignment Plan level. Assignment plan hierarchy threads are ordered sets of assignment plans that may cover consumers concurrently. As an example, recipient (that is, consumer) enrollment is in a managed care assignment plan and level of care assignment plan, the managed care assignment is first in the hierarchy thread, and the level of care is second. Assignment plans and benefit plans cannot be together in a thread since the two plan types are inherently different, one grants coverage (benefit), and the other restricts coverage (assignment).

audits Formal and official examination of finance-related provider records to verify accuracy and compliance with regulations. Audit exceptions may be resolved through restitution or used as part of an investigation.

ATN application tracking number This number is auto-assigned by interChange when an application is successfully submitted.

AVRS Automated Voice Response System Used to supply consumer eligibility information or claims status to providers via telephone.


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AWP average wholesale price A prescription drug term referring to the average price at which wholesalers sell drugs to physicians, pharmacies, and other customers.


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B

BAU business as usual The normal course of an activity, particularly in circumstances that are out of the ordinary.

BCA Bureau of Community Access Effective October 1, 2008, BCA responsibilities were incorporated into the Bureau of Community Services Policy (BCSP). See: BCSP (Bureau of Community Services Policy).

.BCCP Breast and Cervical Cancer Program A federal and state program that helps low-income, uninsured, and medically underserved women gain access to screening programs for early detection of breast and cervical cancers.

BCII Bureau of Criminal Identification and Investigation A resource to law-enforcement agencies throughout Ohio. BCII is part of the Ohio Attorney General’s office.

BCM Bureau of Clinical Management Effective Oct 1, 2008, this bureau became the Clinical Quality Section in the OHP Deputy Director’s Office. See: Clinical Quality Section.

BCMH Bureau of Children with Medical Handicaps A state-administered program which operates within the Ohio Department of Health. The bureau promotes early identification of children with handicapping conditions and treatment of those children by appropriate health care providers.

BCPS Bureau of Consumer and Program Support Effective Oct 1, 2008, this bureau became the Bureau of Eligibility Support and Children’s Health (BESCH). See: BESCH (Bureau of Eligibility Support and Children’s Health).

BCSP Bureau of Community Services Policy BCSP administers the Home and Community-Based Services (HCBS) Medicaid waiver programs operated by ODJFS. Also administers other non-waiver home care benefit packages included in the Medicaid state plan, manages CMS grants, and the state-funded Ohio Access Success Project. The Money Follows the Person (MFP) area is directly responsible for developing and managing universal intake for all MFP activity, tracking MFP participants for CMS reporting, fiscal reporting and evaluation purposes. Community Services Policy includes the following sections:

• Interagency Policy and Program Development – contains two revenue enhancement units that are responsible for using the agency’s Medicaid Administrative Claiming Methodology Guide to


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prepare reimbursement methodologies for state agencies other than ODJFS and to prepare HCBS waiver applications and renewals. (formerly the responsibility of the Bureau of Community Access)

• Community Program Coordination – tracks the Ohio Administrative Code (OAC) rules, manages the Intra State Transfer Vouchers (ISTVs) for other state agencies, and creates Requests for Proposals (RFPs) and contracts. This section also manages the home-care program case management agency, a contracted firm.

• OHP Program Development/Management - performs program design and creates operational policy for home care providers; maintains and monitors the consumer protection-from-harm process; provides oversight for the functions of Success Pilot Program; ensures that the Case Management Agency (CMA) meets federal and department established standards and delivers healthy, safe and high-quality administrative case management services to program consumers; monitors reports of suspicious and unnatural deaths, abuse, neglect and exploitation; and acts as a liaison to other state agencies for protection-from-harm practices.

Formerly the Bureau of Home and Community Services (BHCS). BDF batch definition file

A proprietary file used by Captiva from which batch information is read. BENDEX Beneficiary Data Exchange System

A file containing data from the federal government regarding all persons receiving benefits from the Social Security Administration.

beneficiary Term to designate a Medicare participant eligible for the Ohio Medicaid Buy-In program; used in Qualified Medicare Beneficiary (QMB). This term is used in the Buy-In program instead of consumer.

benefit classification

Classifications are a way of grouping services in a manner that allows policy criteria to be enforced yet minimizes the number of coverage, billing, or reimbursement rules created at the service code level. As an example, a single rule on Evaluation and Management Services instead of a rule on each of a list of procedure codes. This provides a way to avoid creating complex layers of rules on individual service codes that make it difficult to implement new policies. The standard classification is provided with the base system and includes the classification (grouping of services) for all six benefit types (service codes) - Diagnosis, Drug, DRG, HCPCS Procedure, ICD-10-CM Procedure, and Revenue codes. This standard classification structure uses resources as recognized by the Centers for Medicare and Medicaid Services (CMS). These sources include Centers for Disease Control and Prevention (Diagnoses and ICD-10-CM Procedures), Health and Human Services (NDC and HCPCS Procedures), American Dental Association (HCPCS Dental Procedures), and American Medical Association (CPT Procedures).


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benefit coverage Benefit coverage refers to a list of specific benefits, i.e., Diagnosis, Drug, DRG, HCPCS Procedure, ICD-10-CM Procedure, and Revenue code, as covered by the State’s policy for each consumer plan.

Benefit Coverage Rules

Benefit coverage rules describes the conditions or restrictions under which the State will cover the benefit. The system validates the services listed on the claim against the coverage rules to determine how to disposition the claim, in other words, the actual status of a claim to pay, suspend, or deny according to the edit associated to the rule. For example, a benefit only covers specific age ranges or a provider can bill only certain claim types.

benefit plan Benefit plans are a group of covered services (benefits) granted to a consumer deemed eligible for the services the benefit plan represents. A consumer may have multiple benefit plans within the consumer’s HIPAA payer. A HIPAA payer may have multiple benefit plans, but a benefit plan can have only one HIPAA payer.

benefit plan coordination of benefits

See: COB (coordination of benefits).

Benefit Plan Group Type / Benefit Plan Group

Benefit Plan Group Types identify consumer plans that require special processing. Benefit Plan Groups are the individual plans within each group type. For example, a Benefit Plan Group Type can contain the managed care consumer plans; another group type may contain the waiver benefit plans. All consumer plans, both benefit plans and assignment plans, need to be in one of the Benefit Plan Group Types. In a few rare situations, a plan can belong to more then one type, such as both benefit and assignment.

benefit plan hierarchy

Benefit plan threads control benefit plan relationships and the order of claim processing at the benefit plan level. Benefit plan hierarchy threads are ordered sets of benefit plans that may cover consumers concurrently. As an example, a consumer has enrollment in the Title XIX plan and has HCBS coverage, the Title XIX benefit plan is first in the hierarchy thread, and HCBS is second. Benefit plans and assignment plans cannot be together in a thread since the two plan types are inherently different, one grants coverage (benefit), and the other restricts coverage (assignment). Every plan is associated with only one financial payer so the benefit plan hierarchy controls which payer will pay a given service.

benefits A schedule of health care services that an eligible consumer receives for the treatment of illness, injury, or other conditions allowed under the State plan. (Diagnosis, Drug, DRG, HCPCS Procedure, ICD-10-CM Procedure, Revenue codes, and other codes that identify benefits if needed).


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BESCH Bureau of Eligibility Support and Children’s Health BESCH is responsible for the following:

• Defines program information and education needs, facilitates input by communities and consumers into the OHP’s polity and operations;

• Manages a consumer information hotline and premium collection processes;

• Develops eligibility policy for Medicaid, State Children’s Health Insurance Policy (SCHIP), Healthchek, and Pregnancy Related Services (PRS);

• Oversees and supports the county administration of Medicaid and SCHIP programs, and conducts county compliance activities; and develops and implements technical system changes.

BESCH includes the following sections: • County Support – ensures that county agencies administer Medicaid

programs in compliance with the Ohio Administration Code (OAC); specifically programs in the Aged, Blind and Disabled (ABD) and Covered Families and Children (CFC) categories. This section also manages the Ohio Medicaid Consumer Hotline.

• Program Support - Administers Medicaid’s Healthchek (formerly Early and Periodic Screening, Diagnosis and Treatment [EPSDT]) and Pregnancy Related Services (PRS) programs.

Formerly the Bureau of Consumer and Program Support (BCPS). BHCS Bureau of Home and Community Services

Effective Oct 1, 2008, this bureau became the Bureau of Community Services Policy (BCSP). See: BCSP (Bureau of Community Services Policy).

BHPP Bureau of Health Plan Policy BHPP provides leadership to Ohio Medicaid in coordinating initiatives to improve the quality of health care delivered to Medicaid consumers. BHPP promulgates administrative rules that govern the types of services covered, and the methods of provider reimbursement. They are responsible for Medicaid handbooks, manuals of policies and procedures distributed to health care providers and for the Medicaid State Plan. Effective Oct 1, 2008, this bureau became the Bureau of Policy and Budget Management (BPBM). See: BPBM (Bureau of Policy and Budget Management).


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BIAR Business Intelligence Analytical Reporting A base data warehouse subsystem in interChange that provides access to the MITS database and various external data sources. The data is stored in an Oracle Relational Database Management System (RDBMS) and is accessed through the Business Objects application. Within Business Objects, universes are created by subsystem area. The universes remove the technical knowledge needed to develop and run queries in the system. Data elements are given practical names and logically grouped for easy location and selection. The users can use common Windows-like features such as drag and drop to quickly develop queries.

BIC Business Intelligence Channel A database application developed and used by ODJFS’ Information Services.

BIN binary Refers to two parts or two pieces. Usually binary refers to a representation for numbers using only two digits (usually, 0 and 1).

bitonal An image or file comprised of pixel or dot values of either black or white. BITS Background Intelligent Transfer Service

A component of the Microsoft Windows Operating System that facilitates prioritized, throttled, and asynchronous transfer of files between computers using idle network bandwidth. An example of an application that uses BITS is Windows Update services.

blind One of the categories of eligibility in the Medicaid program. An eligible person must be blind under the letter of the law and have income and resources below state defined thresholds

BLOB binary large object A collection of binary data stored as a single entity in a database management system. Blobs are typically images, audio or other multimedia objects, though sometimes binary executable code is stored as a blob.


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BLTCF Bureau of Long Term Care Facilities BLTCF oversees the Medicaid policies for nursing homes and intermediate care facilities for people with mental retardation (ICFs-MR), including reimbursement and contract management. Long Term Care Facilities includes the following sections:

• LTC Provider/Consumer Policy - responsible for Change of Ownership for Providers (CHOP) transaction analysis, escrow, franchise fee, enforcement and civil monetary penalties; operates a help desk for providers, works with Management Information Services (MIS) to design, test, and implement system changes, and conducts clinical and statistical research studies.

• LTC Program Development - coordinates rules development for Medicaid payments to long term care facilities; conducts five year reviews on related rules; and develops the state’s Medicaid cost reports for LTC facilities.

BMC Bureau of Managed Care Develops, administers, and assesses the Ohio Medicaid Managed Care Program (MCP). Staff oversee quality assurance activities, including selecting and executing a contract with an external quality review organization pursuant to federal requirements. Staff develop managed care enrollment policies and select and oversee enrollment services contractors. Specifically, Managed Care employees design purchasing specifications, select qualified managed care plans (MCPs), monitor contracts, review performance, and develop and implement new program initiatives. This area is also responsible for the Children's Buy-In Program. BMC staff also develop and assess managed care delivery systems for Medicaid consumers. BMC includes the following sections:

• MC Enrollment – oversees and manages the enrollment of eligible individuals in Medicaid-contracting MCPs.

• MC Contract Administration - monitors the provider agreements between ODJFS and Medicaid-contracting MCPs and develops operational policies and procedures.

Formerly the Bureau of Managed Health Care (BMHC). BMHC Bureau of Managed Health Care

Effective Oct 1, 2008, this bureau became the Bureau of Managed Care. See: BMC (Bureau of Managed Care).

BO business objects Objects in an object-oriented computer program that represent the entities in the business domain that the program is designed to support


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BOB best of breed Best off-the-shelf product available.

BP business process A collection of interrelated tasks, which accomplish a particular goal. There are three types: Management processes-processes that govern the operation of a system. Typical management processes include Corporate Governance and Strategic Management. Operational processes-processes that constitute the core business and create the primary value stream. Typical operational processes are Purchasing, Manufacturing, Marketing, and Sales. Supporting processes-support the core processes.

BPA Benefit Plan Administration Processes medical, dental, vision, flex and disability claims.

BPEL Business Process Execution Language A language for specifying business process behavior based on Web Services.

BPBM Bureau of Policy and Benefit Management Responsible for the strategic planning and policy development for many aspects of Ohio’s Medicaid program, including the development of the Medicaid state plan. Staff promulgates administrative rules that govern the types of services covered and develops Medicaid handbooks and policy manuals for health care providers, and provides benefit design and pricing functions for the acute care benefit system, including hospital, pharmacy, dental, home health, laboratory, and physician services. BPBM includes the following sections:

• Chapter 1 MITS - develops and implements strategies for value-purchasing health care and facilitates the development of integrated health care delivery systems.

• Non-Institutional - plans and directs the development of policies on non-institutional health care benefits offered under state-administered health plans, and ensures that these policies are in compliance with state and federal requirements.

• Hospital - develops and maintains Ohio’s Medicaid state plan; promulgates administrative rules that govern the types of hospital services covered by OHP’s reimbursement plans; evaluates reimbursement methodologies for hospital providers; conducts training; and prepares and maintains Medicaid provider handbooks and policy manuals for health care providers.

Formerly Bureau of Health Plan Policy (BHPP).


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BPO Bureau of Plan Operations Effective Oct 1, 2008, this bureau became the Bureau of Provider Services (BPS). See: BPS (Bureau of Provider Services).

BPS Bureau of Provider Services Ensures the fiscal integrity and quality of Ohio’s Medicaid program. Provider Services includes the following sections:

• Claims Services - processes fee-for-service, vendor, and capitation adjustments; collects outstanding credit balances; sets up liens and garnishments; establishes and monitors mass payment adjustments for multiple claims and canceled warrants; and maintains the accuracy of online Medicaid history files.

• Claims Processing - responsible for the real-time keyboard entry and verification of data submitted for payment processing.

• Provider Relations – serves as the primary liaison between the medical provider community and the Ohio Medicaid fee-for-service program, providing technical assistance and support to active providers in the Medicaid network

• Network Management - enrolls medical providers into the Medicaid program; maintains the Medicaid Management Information System (MMIS) provider records; analyzes and interprets federal and state regulations and laws and ensures program compliance.

Formerly Bureau of Plan Operations. BR business requirement

The changes in work activities and work practices, usually including the introduction of new information systems and/or services, to help the organization achieve its aims and objectives.

BSH Bureau of State Hearings Assures that hearings in appealed cases are conducted fairly, objectively, promptly, efficiently, and result in quality and timely decisions; a part of the ODJFS Office of Legal Services.

business day See: workday. business process A business process is a methodology for organizing and performing an

activity or sequence of activities to achieve a business goal. Buy-In A program in which Medicaid pays the premiums for Medicare

beneficiaries.


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C

C & F Related to HIPAA 834 transactions: the C transaction reports all eligibility and demographic changes from the previous month’s transaction. The F transaction is a full roster of all eligibles along with their current eligibility and demographics.

CA 1. certificate of authority An entity which issues digital certificates for use by other parties.

CA 2. contract administrator Handles the procedures related to contract projects.

calendar day A twenty-four (24) hour period between midnight and midnight, regardless of whether or not it occurs on a weekend or holiday.

calendar year A twelve (12) month period of time beginning on January 1 and ending on December 31.

CAMS Care Management System A database that houses all Medicaid Managed Care Management program data from MCPs.

CAP 1. corrective action plan Provides conceptual design plans and a description of tasks necessary for the corrective action.

CAP 2. cost allocation plan A document that identifies accumulates and distributes allowable direct and indirect costs under sub-grants and contracts.

CAPICOM Cryptographic Application Programming Interface Component Object Model CAPICOM is an Active-X control created by Microsoft to enable environments that support Active-X to use Microsoft cryptographic technologies.

capitation A payment of a fixed amount per person. Capitation for managed care organizations (MCOs) and administration payments for primary care case managers (PCCMs) are a reimbursement rate paid for each consumer assigned to them through the managed care program. Encounter claims filed to Medicaid are zero-paid because the MCO receives a monthly capitation payment for the consumer, regardless of how many encounters the provider has with the consumer for that month.

CareStar The case management agency (external vendor) for ODJFS. carrier An organization processing Medicare Part B claims on behalf of the federal

government. CAS 1. Central Accounting System

State financial and human resources system replaced by OAKS.


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CAS 2. Contract Administration Section An entity of BMHC responsible for oversight of state contracts.

case management Activities performed on behalf of consumers to coordinate services among health care providers.

case number Number assigned to an Assistance Group for Medicaid eligibility purposes. categorically eligible or needy

Certain categories of people are entitled to receive Medicaid benefits. The state is mandated to provide a defined set of Medicaid services to these categories of people. Examples of categorically needy groups include aged, blind or disabled individuals who meet financial and disability requirements.

CAU Cost Avoidance Unit An program entity of ODJFS.

CBI Children’s Buy-In A public health insurance program available to certain children in Ohio.

CBMRDD County Board of Mental Retardation and Developmental Disabilities Provides services to more than 3,900 individuals with disabilities and their families.

CBT computer-based training Formal course materials delivered thorough an interactive Web-based training application.

CC ClearCase A document repository.

CCAO County Commissioners’ Association of Ohio CCAO represents Ohio's 87 Boards of County Commissioners and the Summit County Executive and Council. CCAO promotes best practices in county government administration and management; advocates on behalf of counties at the State and Federal levels; provides training and technical assistance programs; and provides cost saving service programs for Ohio counties.

CCRB Change Control Review Board A joint ODJFS/EDS committee that oversees the change order process for the implementation of MITS.

CCMIS Call Center Management Information System Enables the manager to view agent and queue statistics in real-time and print a wide variety of standard and customizable reports.

CDA Clinical Document Architecture An XML-based markup standard intended to specify the encoding, structure and semantics of clinical documents for exchange.


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CDC 1. Centers for Disease Control An agency of the United States Department of Health and Human Services. It works to protect public health and safety by providing information to enhance health decisions, and it promotes health through partnerships with state health departments and other organizations.

CDC 2. Child Day Care Regulation of out-of-home child care environments and the administration of the publicly-funded child care program.

CDJFS County Department of Job and Family Services Develops and oversees programs that provide health care, employment and economic assistance, child support, and services to families and children.

CD-ROM compact disk-read-only memory A portable, digital storing device.

CDT Current Dental Terminology A listing of descriptive terms and identifying codes developed by the American Dental Association (ADA) for reporting dental services and procedures to dental benefits plans.

CE content engine A content management system used by FileNet to manage a full range of structured and unstructured data, a metadata repository. See: metadata and repository.

CEU continuing education unit A measure used in continuing education programs, particularly those required in a licensed profession in order for the professional to maintain the license.

CFC Covered Families and Children Ohio’s Healthy Families eligibles (Temporary Assistance to Needy Families or TANF-related Medicaid consumers) and Ohio’s Healthy Start eligibles (SCHIP consumers)

CFDA Catalog of Federal Domestic Assistance Federal assistance information database which incorporates all federal agency programs that provides grants and awards to consumers.

CFR Code of Federal Regulations The federal rules that direct the state in its administration of the Medicaid program and implementation and operation of an MMIS/MITS.

CGI Common Gateway Interface A standard protocol for interfacing external application software with an information server, commonly a Web server.


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CHCS Center for Health Care Strategies A nonprofit health policy resource center dedicated to improving health care quality for low-income children and adults, people with chronic illnesses and disabilities, frail elders, and racially and ethnically diverse populations experiencing disparities in care.

change order Any request to alter the system, whether by refining or modifying existing requirements or adding new requirements. All changes to the system start as a change order and must be entered into iTRACE. Depending on the impact of the change, some changes may be deemed scope changes. Used interchangeably with ‘change order request’ and ‘change request’. All terms replace ‘customer service request’ (CSR).

change order type Indicates whether a change order is a ‘defect’ or ‘change order’. Additional change order types may be added to provide greater granularity for tracking purposes as deemed necessary.

CHIP Children's Health Insurance Program See: Healthy Start.

CHOP change of provider Term used to indicate that a consumer wishes to have a new Medicaid provider.

CHOW change of ownership Term used to indicate that a provider business has a new owner. The business may or may not continue with the same business name. It will keep the same provider identification number.

CI configuration item The fundamental structural unit of a configuration management system.

CICA Context Inspired Component Architecture A revolutionary approach to message design to help resolve the costly proliferation of differing and often incompatible XML messages used for business-to-business data exchange.

CIFS Common Internet File System A protocol that defines a standard for remote file access. CIFS uses Server Message Block (SMB) protocol for shared file and printer access.

CIL Center for Independent Living National leader in helping people with disabilities live independently and become fully participating members of society.

claim A request for Medicaid to pay for health care services. clerk_id Within the database, id_clerk is the field that holds the clerk identification

(ID). The field is eight characters long.


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CLIA Clinical Laboratory Improvement Act (of 1988) A federally mandated set of certification criteria and a data collection and monitoring system to ensure proper certification of clinical labs.

Clinical Quality Section

An entity of Ohio Health Plans in the Deputy Director’s Office, the Clinical Quality Section provides high quality prospective and retrospective clinical oversight for Medicaid services:

• Case Development — provides support services to ensure a medical determination can be made and communicates with providers, case workers and consumers

• Clinical Review — reviews medical documentation to determine program enrollment and medical necessity

Formerly the Bureau of Clinical Management (BCM). CM configuration management

A discipline applying technical and administrative direction and surveillance to: (1) identify and document the functional and physical characteristics of a configuration item; (2) control changes to those characteristics; and (3) record and report changes to processing and implementation status.

CMA Case Management Agency An agency that assists consumers in gaining access to Medicaid and other community-based services.

CMHF Community Mental Health Facility A facility specialized in assisting patients with mental health needs.

CMM Capability Maturity Model An Information Technology (IT) system development methodology developed and promoted by Carnegie Mellon University to measure and certify the methods and controls used by a company or agency in the development of IT systems.

CMMI Capability Maturity Model Integration In software engineering and organizational development is a process improvement approach that provides organizations with the essential elements for effective process improvement.

CMP 1. civil monetary penalties A punitive fine imposed by a civil court on an entity that has profited from illegal or unethical activity. The Securities and Exchange Commission imposes civil money penalties that are usually equal to the gains made from whatever activity it has deemed to be illegal or unethical.

CMP 2. Configuration Management Plan Provides an overview of the organization, activities, overall tasks, and objectives of Configuration Management


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CMS 1. Centers for Medicare and Medicaid Services are the federal agency that administers Medicare and Medicaid, and regulates the certification of agencies and care facilities for people with mental retardation.

CMS 2. County Medical Services A program that funds medical care for uninsured indigent adult county residents.

CMS 1500 The paper claim form used for billing professional claims. Replaces the HCFA 1500.

CMSO Center for Medicaid and State Operations A division within CMS.

CO See: change order. COB coordination of benefits

Defines the coordination of benefits for a consumer enrolled in multiple benefit plans. With the assumption that interChange is processing claims for all payers of those multiple benefit plans, coordination of benefits allows payers and benefit plans to coordinate benefit payments in a multi-payer system. For example, a consumer with dual eligibility may cause two payers and/or benefit plans to pay a benefit on a claim. Under one payer (or Benefit Plan), a benefit may process to pay $10.00 and then a supplemental payer (or Benefit Plan) may pay an additional $2.00. Also referred to as Benefit Plan coordination of benefits.

COHHIO Coalition on Homelessness and Housing in Ohio Involved in a range of housing assistance services in Ohio, including homeless prevention, emergency shelters, transitional housing and permanent affordable housing with linkages to supportive services.

Coinsurance The portion or percentage a Medicare beneficiary assumes For covered services after paying any applicable deductible. Medicaid pays the coinsurance amounts for approved Medicare services for dually eligible consumers.

COLD Computer Output to Laser Disk Process that allows the transfer of documents from mainframe storage, into long-term optical disk storage systems.

COM+ Component Object Model Plus An extension of the Component Object Model and is both an object oriented programming architecture as well as a set of Operating System services.

Completion New A Captiva module that allows an operator to reject and repair data read by the OCR (optical character recognition) engine. The operator will be stopped only on fields that fall below the confidence threshold or have failed a validation edit.


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Completion Verify

A Captiva module that stops operators on key fields identified by the end user. The operator will then validate the data as passed from OCR (optical character recognition) and the Completion New operator before the batch is released into the backend systems.

compound drug A medication that is a combination of two or more pharmaceuticals. CON Certificate of Need

A regulatory process that requires certain health care providers to obtain state approval before offering certain new or expanded services.

consumer A person who has been determined to be eligible for assistance in accordance with the state plan(s) under Title XIV and Title XIX of the Social Security Act, Title V of the Refugee Education Assistance Act, and/or Title IV of the Immigration and Nationality Act. In interChange, the Ohio MITS, the term ‘recipient’ is used for field names and descriptions.

consumer plan Benefit or assignment plan established by the State Medicaid eligibility program when determining which aid category (benefit plan) or restricted service (assignment plan) a consumer should receive.

consumer plan classes

This represents the different kinds of plans: Benefit Plan, Assignment Plan, Beneficiary Only, Tracking, and Other Insurance. Benefit Plan class includes Major, Dependent, Dual, and Stand Alone. These are the only plans that grant coverage. Major: Can stand alone and cannot be combined with any other major plan, like Medicaid. Dependent: Cannot stand alone and can only exist with a major benefit plan. For example, HCDD (Home and Community Based Services – Developmentally Disabled) is a dependent plan that cannot stand alone and can only exist with a major plan, like Medicaid. Dual: Can stand alone or can be combined with certain other plans. For example, Qualified Medicare Beneficiary (QMB) is a dual plan that enables payment of Medicare premiums, deductibles, and coinsurance for eligible beneficiaries. Stand Alone: Can stand alone and no other benefit plan can exist, such as Title XXI, a managed care plan. There are a limited number of services paid on a fee-for-service schedule and they are defined by procedure and national drug codes. Capitation payments are paid for dental, physical, and mental health services. Assignment Plan class includes Managed Care, PCCM, Lock-in, and Level of Care. These plans restrict how services are delivered by assigning a consumer to a certain group of services or to a provider. For example, includes a foster care benefit plan that will cover services for a consumer assigned to a foster care contracting agent. Beneficiary Only Plan class includes plans such as Specified Low Income Medicare Beneficiary (SLMB), Qualified Individual (QI), and others that


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only pay for Medicare premiums but do not cover services. Tracking Plan class does nothing except backend reporting, i.e., tracks a population of beneficiaries but the plan covers no services. For example, the Elderly Care plan that is dependent upon Medicaid coverage, tracks elderly consumer care. Other Insurance Plan classes are plans providing coverage by other carriers. The premiums may or may not be paid by the State.

contingency plan Action(s) to be taken if a previously identified risk event should occur. contact A Contact is an inquiry within CTMS. It holds information such as the

inquirer's contact information, the reason for the inquiry, all actions taken and the resolution of the inquiry.

contract change order

A term used to specifically identify a change to the EDS Ohio MITS contract.

copay Copay is the fee paid by the consumer to the provider at the time the service is rendered, unless the consumer is exempt from that liability.

COR change order request MITS change order requests for development items not in base transfer system or needing revisions from base transfer system. Used interchangeably with ‘change order’.

COS category of service A group of related medical services (such as pregnancy services).

cost sharing A variety of programs by which Medicaid assists a recipient in paying other insurance premiums. See: Medicare cost sharing and MPAP.

COTA Central Ohio Regional Transit Authority Provides bus transportation throughout Franklin County.

COTS commercial off-the-shelf Software products that are designed to be implemented easily into existing systems and readily available to sell to the public.

coverage rules interChange uses rules to define the processing criteria for health care service coverage restrictions, as determined by the State policy for services within a consumer plan. For example, a service is covered for specific age ranges.

CPAO combined provider adjudication order Used for gross adjustments.

C-PORTS Customer-Provider Occurrence Report Tracking System Software tracking tool used to track reports.


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CPT Current Procedure Terminology© Unique coding structure scheme for all medical procedures approved by the American Medical Association - Fourth Edition.

CPU central computer processing unit The part of a computer that interprets and executes instructions.

CQ ClearQuest Configured as the centralized change database for all project change management activity. Used with ClearCase.

CRIS-E Client Registry Information Systems-Enhanced. Database maintained by Ohio Department of Job and Family Services (ODJFS).

CRM Customer Relationship Management Software that automates customer service and support. It also provides for customer data analysis and supports e-commerce storefronts.

crossover claim A claim for Medicare coinsurance on an already paid Medicare claim that electronically “crosses over” from Medicare to Medicaid for payment of the remaining balance (for dual eligibles).

CRV cost report verification Used to verify that reimbursement rates and cost report verification of outpatient hospital cost consulting.

CS child support Payment specifically designated for the purpose of child support (or treated as such) under a divorce or separation agreement. Such payments are neither deductible by the payer nor taxable to the payee.

CSB Children Services Board Ohio state board with oversight responsibilities for children’s services agencies.

CSDVOPS Customer Service Disabled Veterans Outreach Program Specialists Provides a variety of employment and vocational services to our local veterans.

CSEA Child Support Enforcement Agency A county-based agency.

CSHCN Children with Special Health Care Needs Children who are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.

CSR 1. customer service representative The customer service representative may work in a variety of fields, in diverse ways with the principle object of helping customers.


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CSR 2. customer service request Replaced by change order. See: change order.

CSTL Community Services Transmittal Letter An official correspondence on the promulgation of state rules and policies.

CSVER Customer Service Veterans Employment Representative A specialist focused on helping with Veteran employment.

CTMS Contact Tracking Management System The Contact Tracking Management System (CTMS) application provides the means to record, store, and access information associated with customer service contacts. Contacts can originate from consumers, providers, or third parties via telephone, fax, email, mail, Web portal, walk-in, or interface feeds. The clerk handling the contact records or updates information about the contact so that the question or issue can be tracked, routed through the appropriate channels, and resolved in a timely manner.

CTN contract tracking number This is the unique number assigned to each CTMS Contact.

CTS 1. Correspondence Tracking System CTS 2. Caretaker Supplements program CWC Combined Wage Claim

A claim established using base period wages from more than one state. CY calendar year

From January 1 to December 31 of a given year.


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D

D1I1 Data Conversion (D) Production Release 1 (1) Iteration (I) Iteration 1 (1) D1I2 Data Conversion (D) Production Release 1 (1) Iteration (I) Iteration 2 (2) D1I3 Data Conversion (D) Production Release 1 (1) Iteration (I) Iteration 3 (3) D2I1 Data Conversion (D) Production Release 2 (2) Iteration (I) Iteration 1 (1) DA Disability Assistance

Financial, medical, and living assistance for those with disabilities. DACL discretionary access control list

An access control list that is controlled by the owner of an object and that specifies the access particular users or groups can have to the object.

daemon process A daemon (pronounced di-mən) process is a computer program that runs in the background, rather than under the direct control of a user. It is used in UNIX and other computer multitasking operating systems. The process may run on a server either at a scheduled time or triggered by a specific event to complete a predefined set of tasks. Typically daemons have names that end with the letter ‘d’: for example, syslogd, the daemon that handles the system log, or sshd, which handles incoming SSH connections.

DAS Department of Administrative Services Department responsible for providing administrative support and services (e.g., human resources, collective bargaining, procurement, information technology) to state agencies, boards and commissions, local governments and state universities.

day Calendar day, unless specified as a workday DB database

A collection of data stored in a computer system and organized for rapid search and retrieval.

DBA database administrator Staff position responsible for operating, maintaining, and troubleshooting a database.

DBCC database change control DBCS double byte character set

A character set in which all characters are encoded in two bytes. DBID database identifier

Points to the program communication block that identifies the database that is to access on the call.


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DBMS database management system Computer software that manages databases. May use any of a variety of database models, such as the network model or relational model. In large systems, a DBMS allows users and other software to store and retrieve data in a structured way.

DCG Diagnostic Cost Group Models that assess health status and predict resource use.

DCN document control number Used to identify a non-claim document passing through the EDMS system.

DD 1. See: developmental disability. DD 2. disability determination DDE direct data entry DDI Design, Development, and Implementation

Necessary steps in the SDLC. Also, Design, Develop, Implement. DDNS Dynamic Domain Naming Service

A system which allows the domain name data held in a name server to be updated in real time. The most common use for this is in allowing an Internet domain name to be assigned to a computer with a dynamic IP address (i.e., an IP address assigned via Dynamic Host Control Protocol [DHCP]).

DDO Deputy Director’s Office DDO provides the management, direction and coordination with the ODJFS offices of Fiscal Services, Legal Services, and Information Services (IS) necessary to effectively operate the programs within the scope of federal and state laws. It is also responsible for six bureaus and the following sections:

• OHP Project Management • Program Integrity/HIPAA/TPL • Health Services • Clinical Quality (formerly the Bureau of Clinical Management) • Cost Reporting

DEA Drug Enforcement Agency (aka Drug Enforcement Administration) A United States Department of Justice law enforcement agency tasked with combating drug smuggling and use within the U.S. Not only is the DEA the lead agency for domestic enforcement of the drug policy of the United States (sharing concurrent jurisdiction with the Federal Bureau of Investigation), it also has sole responsibility for coordinating and pursuing U.S. drug investigations abroad.

DED 1. Deliverables Expectation Document


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DED 2. Data Element Dictionary A dictionary of data elements in a particular software package.

deductible The amount of out-of-pocket expense a Medicare consumer must meet before Medicare pays for covered services. Medicaid pays the deductible for approved services for dually eligible consumers.

DEERS Defense Enrollment Eligibility Reporting System A computerized database of military sponsors, families and others worldwide who are entitled under the law to benefits.

defect Non-conformance of the system to baseline requirements. deliverable All software, documentation, reports, manuals, and any other item that the

Vendor is required to produce and/or tender to the state under terms and conditions of this contract.

denied claim A claim for which no payment is made to the provider because the claim is for non-covered services, is for an ineligible provider or consumer, is a duplicate of another similar or identical transaction, or does not otherwise meet State standards for payment.

Dependant Plan Data

Plans that are reliant on each other must exist concurrently under a consumer’s list of eligible plans. For example, in order for a consumer to have waiver plan coverage, they must also have Title XIX concurrently.

DESI Drug Efficacy Study Implementation List of less than effective drugs (drugs approved by the Food and Drug Administration solely on the basis of their safety prior to 1962 and drugs identical, related, or similar to them).

developmental disability

A severe, chronic disability that meets all of the following conditions attributable to: Cerebral palsy, epilepsy; or any other condition other than mental illness, found to be closely related to mental retardation because this condition results in impairment of general intellectual functioning or adaptive behavior similar to that of mentally retarded persons, and requires treatment or services similar to those required for those persons. It is manifested before the person reaches the age of twenty-two. It is likely to continue indefinitely. It results in substantial functional limitations in three or more of the following areas of major life activity: self-care; understanding and use of language; learning; mobility; self-direction; capacity for independent living.

DFS Distributed File System A set of client and server services that allow for a large enterprise to organize many distributed Server Message Block (SMB) shares into a Distributed File System. DFS provides location transparency and redundancy to improve data availability in the face of failure of heavy load by allowing shares in multiple different locations to be logically grouped under one folder, or DFS root.


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DHCP Dynamic Host Control Protocol A protocol that can be used by network devices to obtain various parameters necessary for client operation in an Internet Protocol environment. The most basic use of DHCP is to assign an Internet Protocol address, subnet mask, and default router to the client; however, other information such as Domain Name System Name servers, Windows Internet Naming Services servers, and many other options can be delivered to the client via DHCP.

DHHS Department of Health and Human Services Federal agency that oversees Medicaid.

DHO District Hearing Office A entity at the state district level that reviews and adjudicates rulings and appeals.

direct rule A rule added to an individual service code (benefit) that enforces the State policy.

directives Directives represent the requirements necessary to support Medicaid Management Information System. These directives can come in the form of RFP requirements, legislative mandates, State Plan initiatives or policies, etc.

disability Any limitation of physical, mental or social activity of an individual compared to other individuals of a similar age, sex and occupation. Frequently refers to limitation of the usual or major daily activities. Certain people with disabilities are eligible for Medicaid services.

disabled One of the categories of eligibility in the Medicaid program. An eligible person must be disabled under the letter of the law and have income and resources below state defined thresholds.

Disposition The result of processing a claim is the assignment of a status or disposition. The detail disposition information on a specific edit or audit determines the status of a claim.

DLL Dynamic Linked Library Microsoft's implementation of the shared library concept for the Windows Operating environment.

DLT Distributed Link Tracking A service introduced with Windows 2000 intended to resolve problems with outdated shortcuts.


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DMA Disability Medical Assistance The DMA program provides medical assistance to Ohioans who are medication dependent and not eligible for Medicaid. Medication dependent means a licensed physician has certified that the individual has a chronic medical condition that requires continuous medication for a long-term, indefinite period of time. The documentation must also specify that if the prescription is unavailable it could increase the likelihood of experiencing a medical emergency and risk the individual’s employability for at least 9 months.

DME durable medical equipment DME includes certain types of equipment and supplies for consumers (such as hospital beds, walkers, bedside commodes, wheelchairs, oxygen, ventilators, and other equipment) that serves a medical purpose and can stand repeated use.

DMRB Data Model Review Board A committee which reviews proposed changes to the data model.

DNS Domain Name System A hierarchical service that maps computer hostnames into Internet Protocol addresses. DNS services form the foundation of the Internet and are vital to operating systems such as Windows 2003 Server for publishing domain controller and global catalog information to Windows 2003 domain members’ servers and clients via DNS integrated Active Directory Services.

DOB date of birth DOD date of death document divider

Document dividers are used to separate individual sheets within a batch into sets of documents. It is used by Captiva to separate scanned images in sets of documents.


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DoS denial of service A denial of service attack is an attempt to make a computer resource unavailable for intended users.

DPI dots per inch A measurement of resolution for printed data. Generally more dots per inch will yield a sharper image.

DR data retention Storing data for backup and historical purposes.

DRA 1. Disaster Recovery Area DRA 2. Deficit Reduction Act (DRA) of 2005 was enacted to control the impact

of Medicare and Medicaid programs on both federal and state budgets. DRG Diagnosis Related Groups

A system to classify hospital patients into one of approximately 500 groups, also referred to as DRGs, expected to have similar hospital resource use. Developed for Medicare as part of the prospective payment system. DRGs are assigned by a ‘grouper’ program based on ICD diagnoses, procedures, age, sex, and the presence of complications or co-morbidities. Under the prospective payment system, hospitals are paid a set fee for treating patients in a single DRG category, regardless of the actual cost of care for the individual. There are three types of DRGs: basic DRG (based upon Medicare beneficiaries), All Patient DRGs (expanded to include non-Medicare patients), and All Patient Refined DRGs (expanded to create subcategories of the all patient groups).

DRP Direct Reimbursement Program A state program that allows payment to a consumer for certain out-of-pocket expenses.

Drug Rebate Program

Program authorized by the Omnibus Budget Reconciliation Act of 1990 (OBRA-90) in which legend drug manufacturers or labelers enter into an agreement with the Secretary, DHHS, to provide financial rebates to states based on dollar amount of their drugs reimbursed by the Medicaid program.

DSDM Dynamic Data Exchange Share Database Manager Runs as a service on a Windows NT server and maintains a database of shared conversations in support of Network Dynamic Data Exchange (NetDDE).

DSH (DISPRO) Disproportionate Share Hospital The Hospital Care Assurance Program (HCAP) is Ohio's version of the federally required Disproportionate Share Hospital program. HCAP compensates hospitals that provide a disproportionate share of care to indigent patients (Medicaid consumers, people below poverty, and people without health insurance).


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DSM DSM-IV

Diagnostic and Statistical Manual – 4th Edition The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), is published by the American Psychiatric Association. It is the handbook used most often in diagnosing mental disorders in the United States and internationally.

DSMO Designated Standards Maintenance Organization The final HIPAA rule titled ‘Standards for Electronic Transactions’, published in the Federal Register on August 17, 2000, establishes a new category of organization, the ‘Designated Standard Maintenance Organization (DSMO)’. Section 162.910 of this final regulation provides that the Secretary may designate as DSMOs those organizations that agree to maintain the standards adopted by the Secretary. Section 162.910 also establishes criteria for the processes to be used in such maintenance.

DSS Decision Support System Component of a data warehouse that provides analytical-level queries and reporting.

DSSU disk staging storage units DTC Distributed Transaction Coordinator

A component service included with Windows 2000 and later Operating Systems that is responsible for coordinating transactions that span multiple resource managers such as databases, message queues, and file systems.

DUA Disaster Unemployment Assistance Provides financial assistance to individuals whose employment or self-employment has been lost or interrupted as a direct result of a major disaster declared by the President of the United States.

dual eligible A person enrolled in both Medicare and Medicaid. DUR Drug Utilization Review

Drug Utilization Review is a process whereby a pharmacist or pharmacy specialist reviews a prescription and a patient record for therapeutic appropriateness.

DV domestic violence Violence or physical abuse of one's spouse or domestic partner.

DVOPS Disabled Veterans Outreach Program Specialists Specialists regarding outreach programs for military veterans.

DxCG Diagnostic Cost Grouper A diagnosis based risk-adjusted predictive modeling tool that is provided as part of DSS.


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E

EAC estimated acquisition cost Promotion costs associated with securing a new subscriber or customer, such as list rental fees, design, and production.

EAI Enterprise Application Integration The use of software and computer systems architectural principles to integrate a set of enterprise computer applications.

early adopter The term used for the first states that choose to use the CMS MITA architecture in the design of a Medicaid Information Technology system.

EBCDIC Extended Binary Coded Decimal Interchange Code An 8-bit character encoding (code page) used on IBM mainframe operating systems such as z/OS, OS/390, VM and VSE, as well as IBM midrange computer operating systems such as OS/400 and i5/OS.

EBT electronic benefits transfer An electronic system that allows a consumer to authorize transfer of their government benefits from a Federal account to a retailer account to pay for products received.

ECF extended care facility Facilities designed for those who need assistance with day-to-day activities or with medical needs.

ECM enhanced care management Partnering with patients and providers to improve the health and well-being of identified Medicaid enrollees through patient-centered care management services.

ECS electronic claims submission A method of submitting claims other than on paper.

EDB enrollment database Database containing enrollment data.

EDI 1. Set of standards for structuring information that is to be electronically exchanged between and within businesses, organizations, government entities and other groups.

EDI 2. Electronic Data Interchange The Electronic Data Interchange (EDI) subsystem is an interface into MITS for trading partners. It allows trading partners to submit transactions using standardized communication protocols and data structures.

EDIO The EDI online subsystem of MMIS/MITS where trading partner profiles are entered.


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EDMS Electronic Document Management System A subsystem (consisting of a computer system or set of computer programs) used to track and store electronic documents and/or images of paper documents uploaded in a variety of formats.

EDMS Cover Sheet

EDMS coversheet or EDMS scan coversheet is a special type document divider that contains a collection of index values (PA number for prior authorization documents, ATN (application tracking number) for provider enrollment documents, etc). EDMS coversheet is used to file documents into the EDMS. It must accompany PA, PE and correspondence documents as the first document in the stack.

See: document divider.

EDS Electronic Data Systems (Corporation). Now replaced by EDS, an HP Company.

EDS PMO EDS Project Management Office The unit/team responsible for overseeing project management activities, processes, and deliverables.

EDWAA Economic Dislocation and Worker Adjustment Act Provides retraining and readjustment assistance to dislocated workers unlikely to return to their previous industries or occupations. Services include rapid response, occupational skills training, basic and remedial response, occupational skills training, basic and remedial education, job search and placement, supportive services such as child care and transportation allowances, relocation assistance, and needs related payments for dislocated workers who have exhausted their unemployment insurance.

EFS encrypting file system File system driver with file system level encryption available in Microsoft Windows 2000 and later Operating Systems using public key cryptography.


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EFT electronic funds transfer The payment of funds made by electronic direct deposit to a provider's bank account.

EHR electronic health record A record of diagnoses, treatments and laboratory results stored in an electronic record for retrieval and use by authorized treatment professionals. See also: EMR (electronic medical record).

eICMS electronic Integrated Client Management System An automated system providing caseworkers with a common front-end to TANF-supportive systems and a case management toolkit to help the caseworker assist the participants in becoming self-sufficient. The system:

• Assesses and tracks the service delivery of participants as they move through the system toward self-sufficiency;

• Includes a process to collect information to see if participants’ needs can be met before eligibility factors for OWF are determined;

• Records the diversion or referral of a participant to another agency; and

• Matches participants and corresponding service providers through a Resource Directory.

EIN employer’s identification number The same as the federal employer’s identification number (FEIN).

EIS Executive Information System High level management reporting using graphical and tabular reports via the Decision Support System (DSS) to provide upper management data for accessing the overall scope and performance of the Medicaid program.

eligibility file A file that maintains pertinent data for each Medicaid eligible consumer. eligibility verification

Refers to the process of validating whether an individual is determined to be eligible for health care coverage through the Medicaid program and/or a provider is qualified to provide services to the Medicaid population. Eligibility for the consumer and provider is determined by the State.

EMMA Executive Medicaid Management Administration The Provision of Health Services through the Ohio Medicaid Program. The Ohio Medicaid Program is a medical financing and service delivery system.


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EMR electronic medical record A record of diagnoses, treatments and laboratory results stored in an electronic record for retrieval and use by authorized treatment professionals. See: EHR (electronic health record).

EMS Eligibility Management Services Audits carrier records and proactively manage eligibility which leads to saved premium and claims dollars.

EMT emergency medical transportation National and international air ambulance, air medical transport, and emergency air lift services.

encounter data Detailed data about individual health care related services provided by a capitated managed care organization (MCO) or other State designated managed care providers. Encounter data is equivalent to a standard Medicaid claim except that it is submitted to provide service delivery data to the Agency and is not eligible for reimbursement. MCO health care related services are those covered and reimbursed by a per member per month capitated rate payment.

enhancement 1. A major MITS system change that is federally or state mandated and funded by CMS at an enhanced rate

Enhancement 2. A module used by Captiva prepares an image to be read by optical character recognition (OCR). It enhances and removes superfluous data from images such as: line removals, static text removals, image registration, etc.

Enterprise Architecture

The enterprise architecture defines the design guidelines, standards, and preferred technical approaches that provide flexibility and facilitate information sharing and interoperability across an entire enterprise.

EOB explanation of benefits A text description of denial or reduced payment included on the provider’s remittance advice.

EOMB explanation of medical benefits Used by Medicare as an explanation of benefits within Medicare claims processing. Also rendered as ‘explanation of Medicare benefits’.

ePHI electronic protected health information Data in an electronic format related to a consumer that is protected under HIPAA privacy rules.

EPSDT 1. Early and Periodic Screening, Diagnosis, and Treatment See: Healthchek.

EPSDT 2. EPSDT A technical subsystem within interChange.

glossary - medicaid.ohio.govmedicaid.ohio.gov/portals/0/providers/mits/mits... · adf automated...

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